MDS Reordering form

Patient details

Next of Kin Details (if applicable)

Optional
e.g. Husband, Daughter

Re-ordering of medication

As part of this service, we will order your medication on behalf of you. Each month we will be in contact before ordering, to confirm that the medication is still the same from the previous month or if there are any changes, or that the client hasn't entered hospital so won't require the medication etc.

If you are due to order your medication within the next 10 days, please order this yourself and then we will begin ordering the month after that.

 

We have to add all your details onto our medication re-ordering system, and can't confirm that it will all be on there in time to order within the next 10 days.

Access to home information

e.g. Keysafe Number, Patient will answer door, Go round to back door

GDPR Consent

I consent to my data being supplied to my GP surgery in order for Christchurch Pharmacy to request my medication on my behalf
I consent to my contact details being shared with Christchurch Health Centre, so both the Pharmacy, Clinic and Care Agency can contact me regarding offers and packages etc.

Signed